Basic Information
| Provider Information | |||||||||
| NPI: | 1346447190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LEIF | ||||||||
| MiddleName: | BRYNOLF | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PMHNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | LEIF | ||||||||
| OtherMiddleName: | BRYNOLF | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PMHNP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 158 ZILLICOA ST | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288011079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282549494 | ||||||||
| FaxNumber: | 8282984870 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 REDDICK RD | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288052717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282980186 | ||||||||
| FaxNumber: | 8282984870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 07/08/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 213163 | NC | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | 5002627 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.